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What Makes Breast Reduction Medically Necessary?

Posted March 09, 2017 in Breast Enhancement, Breast Reduction, Chronic Pain, Insurance Options, Shoulder Grooves

Breast Reduction Before and After PhotosBreast reduction is unique among plastic surgery procedures because it is one of the few treatments that can be considered “medically necessary.” Many insurance companies will offer coverage if breast reduction can be categorized as medically necessary for the patient. Each insurance company has its own set of criteria, but here are the most common qualifications that are required to be eligible for insurance coverage of breast reduction.

Suffering From Chronic Pain

Patients who suffer from chronic back, neck, and shoulder pain because of their overly large breasts are the most likely candidates to be eligible for coverage. Recurrent inflammatory conditions under the breasts can also be considered an acceptable qualification. These conditions must be monitored and documented by your primary care physician as well as any chiropractor or orthopedic surgeon who has cared for you. These medical professionals may need to submit letters to your insurance company along with evidence that a breast reduction will relieve your symptoms. Insurance companies require evaluative proof that your chronic pain is related to oversized breasts and not the result of back or spine problems.

Permanent Shoulder Grooves

Grooving on the shoulders from overtaxed bra straps are a symptom of heavily weighted breasts. It is common for women with large breasts to develop permanent indentations in their shoulders from their bra straps. This condition, especially in conjunction with chronic pain, may qualify you for breast reduction coverage.

No Alternative Treatments Have Worked

Some insurance companies require you to try alternative treatments. For instance, they may require you to prove that methods such as physical therapy, chiropractic treatments, and weight loss have not been able to improve your symptoms. These techniques may help some women alleviate chronic pain caused by their oversized breasts, but in most cases, these methods are unsuccessful. Women who have tried these non-surgical methods without success can use them as additional evidence to help them qualify for a medically necessary breast reduction.

A Certain Amount of Tissue Must Be Removed

Most insurance companies require a certain amount of breast tissue to be removed in order to qualify for coverage. Large reductions, such as from a G cup down to a C cup, are often covered. Breast reductions that remove at least 500 grams from each breast are frequently covered as well. The amount varies between insurance companies, and some consider your height and weight when determining how much tissue must be removed. However, women who are trying to get coverage should not necessarily have more breast tissue removed just to receive coverage, as they may be unhappy with their small breast size afterward.

Getting Your Procedure Covered

If you are suffering from unpleasant symptoms that can be attributed to your oversized breasts, speak with your physician and contact your insurance company to determine your eligibility for coverage. If your first request is denied, demand an appeal, and with the help of your surgeon, you may be able to get your procedure covered. Women who undergo breast reduction for medically necessary reasons are often highly satisfied with the results. Breast reduction can solve many of these symptoms and improve your quality of life as well as your appearance.

Dr. Andrés Taleisnik is an experienced, board-certified plastic surgeon who performs breast reduction surgery to help women like you have a relief of symptoms and more balanced body proportions. He and his staff may be able to help you work with your insurance provider to help qualify you for coverage of your breast reduction procedure.

To request your personal consultation, call (714) 538-8549 or complete our online contact form today.